Mrs A complained about the care given to her late father, Mr Y, when a patient at Glan Clwyd hospital in 2009. She said that there were delays in his diagnosis and treatment. Sadly Mr Y died on 7 November 2009 following extensive surgery to drain a perianal abscess and treat the quickly progressing and very serious infection which developed.
The Ombudsman upheld Mrs A’s complaint. He found that delay in diagnosis and in carrying out surgery were significant factors in Mr Y’s death. His main findings were:
• lack of review by a consultant urologist;
• failure by doctors to record consistently and act upon significant test results to review the initial diagnosis;
• poor communication between medical staff and with the family. There were missed opportunities to obtain information from the family, given that Mr Y had Alzheimer’s disease and communication difficulties;
• no overall plan of nursing care for Mr Y and a failure to reassess as his condition deteriorated;
• a criticism of the decision not to carry out surgery late at night and the lack of direct dialogue between the consultant anaesthetist and consultant surgeon.
The Health Board agreed to make a payment of £3,000 for the trauma caused to the family for the distressing way in which Mr Y died and the knowledge that the delays contributed to the sad outcome. The Ombudsman made a range of recommendations for the review of procedures, audit and training His recommendations were accepted by the University Health Board.
The full report can be downloaded below.